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2006; 86:1641-1650.PHYS THER. Michael Kriz and Nicole SaltzmanJames Stephens, Joshua Davidson, Joseph DeRosa,Stretching Using ''Awareness Through Movement''Lengthening the Hamstring Muscles Without

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Lengthening the Hamstring MusclesWithout Stretching Using “AwarenessThrough Movement”

Background and Purpose. Passive stretching is widely used to increase muscleflexibility, but it has been shown that this process does not produce long-termchanges in the viscoelastic properties of muscle as originally thought. Theauthors tested a method of lengthening hamstring muscles called “AwarenessThrough Movement” (ATM) that does not use passive stretching. Subjects.Thirty-three subjects who were randomly assigned to ATM and control groupsmet the screening criteria and completed the intervention phase of the study.Methods. The ATM group went through a process of learning complex activemovements designed to increase length in the hamstring muscles. Hamstringmuscle length was measured before and after intervention using the ActiveKnee Extension Test. Results. The ATM group gained significantly morehamstring muscle length (�7.04°) compared with the control group(�1.15°). Discussion and Conclusions. The results suggest that muscle lengthcan be increased through a process of active movement that does not involvestretching. Further research is needed to investigate this finding. [Stephens J,Davidson J, DeRosa J, et al. Lengthening the hamstring muscles withoutstretching using “Awareness Through Movement.” Phys Ther. 2006;86:1641–1650.]

Key Words: Awareness Through Movement, Feldenkrais method, Hamstring, Muscle lengthening, Stretching.

James Stephens, Joshua Davidson, Joseph DeRosa, Michael Kriz, Nicole Saltzman

Physical Therapy . Volume 86 . Number 12 . December 2006 1641

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The hamstring muscles are important contribu-tors to the control of human movement and areinvolved in a wide range of activities fromrunning and jumping to forward bending dur-

ing sitting or standing and a range of postural controlactions. Hamstring muscle strains are the most commonmuscle injuries in athletes.1 The proposed etiologyincludes insufficient flexibility, strength (force-generating capacity) impairment or imbalance, and dys-synergic contraction that can place excessive strain onthe hamstring muscles.2 Static stretching of the ham-string muscles, to maintain flexibility and improve per-formance,2–4 has been proposed as a proactive andpreventive strategy and is now in common use. Studieswith collegiate football players5 and military basic train-ees2,6 document the success of this strategy in reducingthe rates of lower-extremity injuries.

Reduced hamstring muscle flexibility has been impli-cated in lumbar spine dysfunction, with a number ofstudies7–10 showing a strong positive correlation betweendecreased hamstring flexibility and low back pain. Otherresearchers10–13 have suggested that hamstring musclefunction in a variety of movements is part of a coordi-nated motor program and thus the appropriate periodsof lengthening and shortening and perhaps even thedegree of lengthening itself may be a learned part of themotor control process.

A variety of methods have been used to increase ham-string muscle flexibility, including static stretch,14 pro-prioceptive neuromuscular facilitation,15 dynamic rangeof motion,16 and active motion in the neural slumpposition.17 None of these methods, however, uses aprocess of active motion without pushing or holding atend-range to achieve its intended results.

“Awareness Through Movement” (ATM) is a process ofverbally guiding a person through an activity duringwhich movements usually are performed slowly andgently. It is thought that this process facilitates thelearning of strategies for improving organization andcoordination of body movement by developing spatialand kinesthetic awareness of body-segment relationshipsat rest and during motion, awareness of ease of move-ment, reducing effort in action, and learning the feelingof longer muscles in action.18,19 This process has beenshown to improve balance and coordination in peoplewith multiple sclerosis20 and balance and mobility inpeople with chronic cardiovascular accident.21

There has been limited study of this approach to ham-string muscle lengthening. Researchers in Australiafound no effect of ATM on hamstring muscle lengthwith a very brief intervention.22,23 The purpose of ourstudy was to test the hypothesis that ATM can be usedeffectively to increase the active length of the hamstring

J Stephens, PT, PhD, CFP, is Assistant Professor, Physical Therapy Department, College of Health Professions, Temple University, 3307 N BroadSt, Philadelphia, PA 19140 (USA). Dr Stephens is a Certified Feldenkrais Practitioner (CFP) and member of the Feldenkrais Guild of NorthAmerica (FGNA). He has served as Chair of the Research Committee of FGNA. There are no financial ties. Address all correspondence to DrStephens at: [email protected].

J Davidson, PT, DPT, CSCS, is Sports Physical Therapist, Golf Performance Specialist, and Certified Strength and Conditioning Specialist, TheSports Medicine and Performance Center at The Children’s Hospital of Philadelphia, King of Prussia, Pa.

J DeRosa, PT, MSPT, is Owner/Physical Therapist, Eastern Shore Physical Therapy, Linwood, NJ.

M Kriz, PT, MSPT, is Staff Physical Therapist, Bonita Springs Sports and Physical Therapy, Bonita Springs, Fla.

N Saltzman, PT, MSPT, is Physical Therapist, Physical Therapy Consultant Group, Scottsdale, Ariz.

Dr Stephens provided concept/idea/research design and institutional liaisons. Dr Davidson provided data collection. Dr Stephens, Dr Davidson,and Mr Kriz provided writing, data analysis, project management, facilities/equipment, clerical support, and consultation (including review ofmanuscript for submission). Assistance with writing, data analysis, and clerical support also was provided by Mr DeRosa and Nicole Saltzman. Theauthors acknowledge the assistance of Melinda Bartscherer, who facilitated institutional relations in her role as Acting Chair of the Institute forPhysical Therapy Education at Widener University when the study was done and Jeff Lidicker, PhD, at the College of Health Professions, TempleUniversity, for his assistance with statistical analysis.

This study was approved by the Widener University Committee for the Protection of Human Subjects.

This research, in part, was presented as a poster at PT 2000: Annual Conference and Scientific Exposition of the American Physical TherapyAssociation; June 5–8, 2000; Cincinnati, Ohio.

This article was received July 1, 2004, and was accepted August 11, 2006.

DOI: 10.2522/ptj.20040208

1642 . Stephens et al Physical Therapy . Volume 86 . Number 12 . December 2006 by guest on July 18, 2015http://ptjournal.apta.org/Downloaded from


muscles. We chose to look at active length because webelieve that this measure is more meaningful thanpassive length in relation to normal functional move-ment and motor control.

Method and Materials

SubjectsFifty-one subjects were recruited using posters and wordof mouth from the population of graduate students andfaculty at the Widener University, Chester, Pa, campus.The purpose of the study was explained, and volunteerssigned an informed consent form approved by theWidener University Committee for the Protection ofHuman Subjects.

Subjects qualified for the study if they did not have ahistory of orthopedic problems, including surgery orinjury to the back, pelvis, or lower extremities or neuro-logic dysfunction (eg, multiple sclerosis, cerebral palsy,or peripheral neuropathy) within 1 year from the begin-ning of the study. Subjects also were excluded from thestudy if they had an active knee extension angle greaterthan 165 degrees (full extension�180 degrees) mea-sured using a quick-screen active knee extension test inwhich the subject lay supine with the hip flexed to 90degrees and actively extended the knee.17 If active kneeextension was judged to fall outside of the desired rangeas marked on a plexiglass template, based on visualassessment, subjects were excluded.

Seven of the 51 subjects did not meet the screeningcriteria because their hamstring muscle length exceededthe maximum standard. Six subjects withdrew for per-sonal reasons before group assignment. The remaining38 subjects were randomly assigned to a group thatreceived ATM intervention (ATM group [n�20]) or agroup that received no intervention (control group[n�18]). Five subjects (2 in the ATM group and 3 in thecontrol group) were dropped from the study after groupassignment. Two of these subjects left the graduateprogram, 2 subjects missed the final data collectionbecause of sickness or travel commitments, and 1 subjectwithdrew because of an acute ankle sprain sustainedwhile running during the period of the study. Thirty-three subjects (18 in the ATM group and 15 in thecontrol group) met the screening criteria and com-pleted the intervention phase of the study.

All subjects were asked to refrain from beginning anynew physical activity, including hamstring musclestretching, that had not been part of their regularactivity prior to the 3-week period of the intervention.Subjects in the ATM group were asked to perform a15-minute ATM session 5 times per week guided by anaudiotaped ATM lesson sequence. Subjects in the con-trol group performed their regular daily activities. The

ATM group was made up of 7 male and 11 femalesubjects who ranged in age from 22 to 36 years(25.9�3.8) (X�SD) and had a pretest hamstring musclelength measurement of 141.96�7.89 degrees. The con-trol group was made up of 6 male and 9 female subjectswho ranged in age from 21 to 27 years (23.9�1.9) andhad a pretest hamstring muscle length measurement of140.66�8.19 degrees. There were no statistically signifi-cant differences between ATM and control groups basedon age, sex, or pretest hamstring muscle length.

InstrumentationActive knee extension hamstring muscle length wasmeasured as the highest value in the range of kneeextension using a PEAK Motus motion analysis system.*Accuracy of angle measurement for this system has beenreported to be less than 0.1 degree, with an intraclasscorrelation coefficient (ICC) of .99.24 An S-VHS Pana-sonic CL-700 digital video camera was placed 7.6 m(25 ft) from each subject and centered on a lineperpendicular to the plane of motion of the subject’sknee. Movement was recorded on a Sanyo editing S-VHSrecorder at 60 frames per second and digitized usingPEAK Motus software. An alignment apparatus similar tothat described by Scholz and Millford24 was constructedof 3.81-cm (1.5-in) diameter PVC pipes. Two verticaluprights 0.91 m (3 ft) in length were connected by acrossbar. The footings of each upright were secured to astandard plinth by 2 Stanley Quick Grips.† Reliability ofknee angle measurements was determined using ICCs(2,3). A set of 3 repeated measurements from eachsubject was used for pretest and posttest calculations.The pretest ICC was .976, and the posttest ICC was .995.

Experimental Procedures

Measurement protocol. The hamstring muscle length ofall subjects who met the screening requirements wasmeasured using the Active Knee Extension Test(AKET)25 1 week prior to beginning the intervention.Hamstring muscle length was measured again 1 to 2 daysafter the end of the intervention period. Subjects werepositioned supine on a standard 0.9-�1.8-m (3-�6-ft)plinth under the alignment apparatus. A 10.2-cm-wide(4-in-wide) Velcro strap‡ was placed around the subjectat the level of the anterior superior iliac spine to stabilizethe pelvis and lumbar spine. An additional 10.2-cm-wideVelcro strap was placed over the left thigh to stabilize thepelvis and left lower extremity. The subjects’ right hipwas flexed to 90 degrees until the anterior thigh was justtouching the crossbar of the alignment apparatus.

* Peak Performance Technologies Inc, 7388 S Revere Pkwy, Suite 901, Centen-nial, CO 80112. The Panasonic camera and Sanyo VCR were obtained as part ofthe PEAK Motus system.† Stanley Tools Group, 480 Myrtle St, New Britain, CT 06053.‡ Velcro USA Inc, 406 Brown Ave, PO Box 5218, Manchester, NH 03103.

Physical Therapy . Volume 86 . Number 12 . December 2006 Stephens et al . 1643

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Reflecting markers 2.54 cm (1 in) in diameter wereplaced on the subjects’ right lower extremity over thegreater trochanter, the middle of the lateral joint line ofthe knee, and the lateral malleolus. Proper alignment ofthe right thigh parallel to the vertical post of thealignment apparatus and perpendicular to the horizon-tal surface of the plinth was verified using the videomonitor (Fig. 1).

Subjects were told to maintain the position of theanterior thigh in light contact with the crossbar of thealignment apparatus. They were permitted to use a towelwrapped around the posterior right thigh just proximalto the knee throughout the test procedure to maintainanterior thigh contact with the crossbar. The startingposition for the test was with the anterior thigh touchingthe crossbar of the alignment apparatus and the rightknee in a relaxed and fully flexed position. One repeti-tion of a knee extension movement consisted of movingthe knee into extension until a feeling of resistance fromthe stiffness of the hamstring muscle stopped the move-ment and then returning to the starting position. Sub-jects were told to begin a series of extension movementswhen one of the researchers gave a “go” signal and tocontinue until a “stop” signal was given. Movements werepaced at one per 2 seconds using a watch and givingverbal cues of “up” during the extension phase and“down” during the flexion phase of the movement. Thetimer gave a “ready” signal 3 seconds before the begin-ning of the procedure. The researcher responsible fordata collection began recording with the PEAK systemjust before the beginning of the first repetition and

continued for the collection of 6 full repetitions for thepretest and posttest for each subject. Repetitions 4through 6 only were used as measures of hamstringmuscle length to allow all subjects the same amount ofpractice and warm-up time before the measured trials.Subject data were identified by number only, and theresearcher responsible for determining knee angle fromthe PEAK data was not aware of the group to which eachsubject was assigned.

Intervention. The ATM intervention was given over a3-week period and consisted of an initial group traininglesson and a home practice program. All subjects in theATM group participated in the initial 30-minute class-room lesson targeting movements of the right lowerextremity. The lesson consisted of an introduction plus 3movement segments, with each segment covering varia-tions of movements requiring lengthening of the ham-string muscle in different postural configurations. Thislesson was recorded on audiotape, and a copy was givento each subject in the ATM group for independenthome practice during the course of the study. TheAppendix gives a description of the audiotaped ATMlessons.

Each segment of the lesson began and ended with a bodyscan in the supine position. This scan was designed tomake subjects aware of their quality of neuromuscularcontrol, including the rate and depth of breathing, thelevel of neuromuscular system tension throughout thebody from the jaw to the feet, and the effort involved insimple movements such as rolling the leg left and right.The first movement segment began with the subjectslying on their left side. In the second movement seg-ment, subjects sat in a long-sitting position. The thirdmovement segment was done in the standing position,beginning with the hips and knees flexed and the pelvisposteriorly tilted. In each segment, movements weresuggested in which subjects flexed and extended theright knee, tilted the pelvis forward and back, androtated the right hip with the head and upper extremi-ties in various positions. The goal was for subjects tolearn to extend the knee, medially (internally) rotate theextending leg, and anteriorly tilt the pelvis at the sametime, an organization of movements designed tolengthen the hamstring muscle from both ends.

As with all other movements in the lesson, these move-ments were done slowly and continuously, with thesubjects resting when tired, and within a comfortablerange of movement, noticing when effort in other areasof the body interfered with these specific movementintentions and trying to reduce those efforts and breatheeasily through the entire process. Subjects were toldexplicitly not to push into the end-range of knee exten-sion as they might if they were doing active or passive

Figure 1.Setup for measuring hamstring muscle length using PEAK Motus motionanalysis system.



end-range stretching. Variations of the options of rotat-ing the hip medially and laterally (externally), extendingand flexing the knee, and tilting the pelvis were sug-gested. Subjects in the ATM group were asked to use theguidance of the audiotaped ATM lesson sequence untilthey were comfortable with the process of exploring themovements suggested, at which time they could proceedwithout the guidance of the audiotape. All subjects wereasked to keep an activity log that included leisure andexercise activities and for the ATM group also includedthe frequency and duration of their ATM practice.

Data AnalysisThe dependent variable of interest was hamstring mus-cle length as measured by the maximum active kneeextension angle. Three trials per subject from eachmeasurement session were recorded, and the mean wasused for data analysis. A 2-factor repeated analysis ofvariance (ANOVA) (group � time) was used with time asthe single repeated measure.26 An alpha level of .05 wasused as the criterion for significance of difference.

Subjects in the ATM group practiced independentlyover a period of 3 weeks and differed widely from eachother in their number of practice sessions and totalminutes practiced. Furthermore, because all subjects inthe ATM group did not follow the same practice sched-ule, their postintervention hamstring muscle lengthmeasurements were done with different periods of delayfollowing the time of their final practice session. Toassess the possible effects of these practice and delayvariables on the outcome measure of hamstring musclelength, a post hoc multiple regression analysis was done.26

The number of practice sessions, total minutes of prac-tice, and delay (in days) were used as independentvariables with the dependent variable of hamstring mus-cle length change within the ATM group. In this analysis,a significance level of �.05 would indicate that theindependent variable made a significant contribution tothe prediction of the outcome measure of hamstringmuscle length change. All statistical analyses were doneusing SPSS version 11.0.4 for Macintosh.§

At the end of the intervention period, subjects in theATM group were asked the question: “From your expe-rience of ATM, would you say that this process isdifferent from stretching, as you understand it?” Afterthe hamstring muscle length change analysis was com-pleted, subjects in the ATM group were divided into 3levels based on the amount of muscle length change.Five subjects achieved no change in muscle length(X�0.1°, range� �3.4°–2.6°). Six subjects achieved amoderate amount of change (X�6.1°, range�4.6°–6.8°). Seven subjects achieved a large amount of change

(X�12.9°, range�9.1°–17.5°). One person representingeach of these levels was interviewed using open-endedquestions to assess their understanding of and experi-ence and strategies in practicing the ATM lessons. Thesequalitative data were used to help interpret the quanti-tative data collected.

ResultsThe mean change in hamstring muscle length in theATM group was �7.04 degrees compared with thecontrol group change of �1.15 degrees (Tab. 1). Therewas a significant increase in hamstring muscle lengthover time and an interaction of group � time, indicatingan increase in hamstring muscle length in the ATMgroup compared with the control group (P�.005)(Tab. 2, Fig. 2).

Table 3 shows the number of practice sessions, totalminutes of practice, and change in hamstring musclelength for each subject in the ATM group. There waswide variation in the amount of practice among subjects.The range for number of sessions was 7 to 18, and totalminutes of practice ranged from 80 to 300 over the3-week period of the intervention. The delay betweenthe last practice session and the final hamstring musclelength measurement ranged from 1 to 10 days. Theregression analysis (Tab. 4) showed that there was nosignificant effect on hamstring muscle length change inthe ATM group as a result of number of practicesessions, the total number of minutes of practice, oramount of delay between the last practice session andthe final hamstring muscle length measurement.

§ SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Table 1.Change in Hamstring Muscle Length Measured in Degreesa

Group Time X SD

ATM (n�18) Pretest 141.96 7.89Posttest 149.00 7.40

Control (n�15) Pretest 140.66 8.19Posttest 141.81 7.61

a Full extension�180 degrees. ATM�Awareness Through Movement.

Table 2.Two-Factor Analysis of Variance With One Repeated Measure (Time)and Hamstring Muscle Length as the Dependent Variable

df F P

Group 1 2.807 .104Time 1 17.779 �.001a

Group � time 1 9.177 .005a

a Significant difference.


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Discussion

Outcome and Stretching LiteratureThe data suggest that selected ATM lessons are aneffective method of increasing active hamstring musclelength and flexibility. This is the first time that a methodthat does not involve stretching has been shown toincrease muscle length.

The only previously published research on the effect ofATM on hamstring muscle lengthening showed that theeffects of ATM were no different from the effects seen ina wait-list control group or a relaxation training controlgroup over the study period.22,23 James et al22 suggested

3 possible problems with their study that might explaintheir observation of no change in hamstring musclelength. First, the subjects may not have had enoughopportunity within their intervention process to performATM lessons directed toward lengthening the hamstringmuscles. Their intervention included 4 ATM lessons, butonly 1 ATM lesson was directed toward lengthening ham-string muscles. The specificity of training concept27 sug-gests that it is unlikely that lessons directed only towardother muscle groups, movements, or areas of the bodywould contribute in any significant way to lengthening thehamstring muscles. Although some practitioners of Felden-krais method claim that significant changes can beobserved from a single lesson,28 there is no publishedliterature documenting that such changes are stable overany length of time greater than a few hours. We agree withJames and colleagues’ suggestion that a single session maynot have been sufficient to produce stable change.22 There-fore, we designed our intervention to be carried out over a3-week period with the number of intervention sessionssimilar to what has been used in published studies usingother approaches (Tab. 5).

Second, James et al22 thought that their subjects mayhave had some negative preconceived ideas about theusefulness of ATM, and therefore may have not cooper-ated fully with the intention of the intervention. Wecannot rule out this possibility in our subjects. Althoughmost of our subjects were physical therapist students, aswere James and colleagues’ subjects, some of them hadheard of the Feldenkrais method but had no priorexperience or other specific knowledge.

Third, James et al22 suggested that, because the motorpattern of the hamstring muscle lesson used during theintervention was not the same as that used in measuringthe outcome of training, a pattern was learned in thelesson that did not transfer to the test measure. Thispossibility is refuted by our results. Our interventionoffered 3 different forms of hamstring muscle lengthen-ing activity, none of which was the same as the testmeasure. In our training audiotape, we suggested that

Table 3.Data for Number of Practice Sessions, Total Minutes of Practice,Posttest Measurement Delay, and Muscle Length Change for Subjectsin the “Awareness Through Movement” Group

SubjectNo.

No. ofPracticeSessions

TotalMinutes ofPractice

PosttestMeasurementDelay (d)

MuscleLengthChange (°)

32 12 275 1 17.519 11 165 1 15.150 8 125 2 13.64 12 120 1 13.1

11 12 180 1 11.31 7 105 2 10.3

33 11 180 2 9.116 13 210 1 6.845 14 210 1 6.649 11 135 8 6.69 13 195 2 6.2

24 10 230 1 5.638 8 80 2 4.635 7 105 10 2.626 NAa NA 2 1.323 18 300 1 0.041 7 135 1 0.051 18 260 1 �3.4Mean 11.3 177.1 2.2 7.0

a “NA” indicates subject did not turn in activity report.

Figure 2.Interaction plot for means test. ATM�“Awareness Through Movement.”

Table 4.Within-Group Multiple Regression Analysis of Effects of Practice(Number of Practice Sessions and Minutes of Practice) and PosttestMeasurement Delay With Hamstring Muscle Length as the DependentVariable for Subjects in the “Awareness Through Movement” Group

Variable B SE Beta t P

No. of practicesessions

0.1910 0.7620 0.2496 0.2507 .8054

No. of minutes ofpractice

0.0202 0.0462 0.4207 0.4367 .6685

Posttest measurementdelay (d)

0.2276 0.6060 0.0841 0.3756 .7125



subjects learn all 3 forms and choose for themselveswhich forms they would practice. We made this choicebased on pilot data that suggested that the 3 differentforms of practice might produce equivalent results. Thisidea is supported by recent data showing that 2 methodsof static hamstring muscle stretching—1 standing and 1supine—had equivalent outcomes.29 Thus, we did notcontrol this variable and do not know exactly whatsubjects did in this regard. Subjects may have selectedany 1 form or some combination of the 3 forms over thetraining period.

The results reported here compare favorably withaccepted methods of stretching that have been reportedin the literature. Table 5 shows a representative sampleof studies published between 1994 and 2004 all of whichused the same method of measuring outcome, theAKET. These data indicate that ATM is comparable tocommonly used stretching methods in the rate andamount of hamstring muscle length gain that is pro-duced over similar periods of time.

Limitations and Future ResearchOne of the limitations of our study is that we did not usea stretching control group. We made this choice basedon the fact that there is a large amount of literature onvarious methods of hamstring muscle stretching thatwould serve as a valid comparison. This allowed us tomaximize our sample size for experimental subjects.

We did not monitor the practice of our subjects. Thus,there was a concern that they may have slipped into afamiliar pattern of doing stretching rather than ATM as

taught. There are 2 reasons why we think that oursubjects did ATM and not stretching. First, we instructedall subjects in the ATM group during the training sessionto be sure that they understood the difference betweenATM and stretching and that movements in the ATMlessons were to be done slowly, not held at the end-rangeand with no strain at the end-range. We audiotaped thisinstruction session and gave subjects a copy of theaudiotape to guide their practice sessions at home.

Second, we asked subjects on an exit survey: “From yourexperience of Awareness Through Movement, wouldyou say that this process is different from stretching asyou understand it? If yes, please briefly describe thedifferences.” Ninety-four percent (17/18) of the subjectsin the ATM group stated that ATM was different fromstretching. Representative comments describing the dif-ference were: “slower and more repetitive”; “I concen-trated more on the movements”; “when I stretch, I justgo through the motions”; “didn’t stress my back, feltfluid”; “moving rather than static”; “did not hold as in astretch”; “more difficult because using muscle groupstogether that do not normally seem related”; “didn’texperience the customary burn associated with stretch-ing”; “didn’t feel as if I had exercised at all”; “moresensing where the muscle was and whether it was length-ening from my awareness”; “not prolonged as in stretch-ing . . . more of a movement pattern”; and “lots of move-ment involved.” Subject 32, who had the largest musclelength gain at 17.5 degrees, said that the movementswere difficult at first and that he strained, causingdiscomfort that persisted into the next day. After the firstweek, he stopped pushing the limits, did fewer and

Table 5.Hamstring Muscle Stretch Literature Resultsa

Article, Year of Publication N Groups and Time Results Rate of Gain (°/wk)

Worrell et al,3 1994 19 2 groups (SS, PNF)4 � 20 s/d5 d/wk15 sessions in 3 wk

SS�8.0°PNF�9.5°

SS�2.7°PNF�3.2°

Webright et al,17 1997 40 2 groups (SS, NBS)2/d � 7 d/wk84 sessions in 6 wk

SS�8.9°NBS�10.2°

SS�1.5°NBS�1.7°

Bandy et al,16 1998 58 3 groups (CON, SS, DROM)CON: no stretchSS: 1 � 30 s/d, 5 d/wkDROM: 6 � 5 s/d, 5 d/wk

CON�0.7°SS�11.4°DROM�4.3°

SS�1.9°DROM�0.7°

Decoster et al,29 2004 28 2 groups (standing SS, supine SS)3/d � 3 wk

Stand�9.1°Supine�8.4°

Stand�3.1°Supine�2.7°

Current study 33 2 groups (CON, ATM)CON: no stretchATM: 15 min/d, 5 d/wk15 sessions in 3 wk

CON�1.1°ATM�7.0°

CON�0.4°ATM�2.4°

a All studies used the Active Knee Extension Test (AKET) to measure hamstring muscle length and did intervention 5 days per week over some period of weeks.SS�static stretch, PNF�proprioceptive neuromuscular facilitation, NBS�nonballistic stretch, DROM�dynamic range of motion, CON�control, ATM�“AwarenessThrough Movement.”


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smaller movements, and began to notice changes such asthe back pain that he usually experienced in class waseliminated. Subject 38, who had a low intermediate gainat 4.6 degrees, said that he never was able to master theside-lying movements and that coordinating difficultmovements caused a strain. He also said that ATM feltlike stretching except that it also incorporated theanterior pelvic tilt, which was difficult. Subject 51, whohad the lowest length gain at �3.4 degrees, also had thelongest hamstring muscles at the outset. She stated thatshe mastered the movements but was surprised that shequalified for the study because she was not aware thather hamstring muscles were short. From these proceduresand comments, we conclude that the subjects were adher-ent to the process in which we instructed them and did notdo stretching, with one possible exception (subject 38).

Another limitation may be the practical aspect of theamount of practice time that was required to produce anoutcome. In our study, subjects practiced an average of15 minutes per session-day compared with 30 secondsper session-day in the study by Bandy et al16 or 80seconds per session-day in the study by Worrell et al,3 asdescribed in the procedures noted in the studies cited inTable 5. Why would anyone want to spend 15 minuteswhen equivalent results could be obtained more quickly?We have shown here that, within the ranges of duration(7–18 sessions) and number of minutes (80–300) thatour subjects practiced (Tab. 3), these variables did nothave an effect on the amount of hamstring musclelength change that occurred (Tab. 4). In an unpub-lished pilot study exploring whether ATM practice timecould be reduced, we have found that equivalent resultsmay be achieved with as little as 15 seconds to 2 minutesper session-day, which is well within the time range of thestretching protocols. Further research is needs to bedone to investigate this possibility.

There has been an interest in describing ATM as aprocess of motor learning.30,31 Unfortunately, our studywas not done using a formal motor learning design,which would have included a number of muscle lengthmeasurements during the acquisition period followed bypost-acquisition retention or transfer tests after somedelay.27 Because of this design difference, we cannot assessour result in terms of motor learning as some practitionersof ATM would like. This is also an area for future research.

We propose that the benefits of an ATM approach toflexibility might be valuable in 3 areas. First, Agre2

suggested that dyssynergic control, which he defined asexertion of too much force at the wrong time or poortransition in functional role (eg, eccentric knee exten-sion control to concentric hip extension in gait), is acommon etiology for hamstring muscle injury. Researchis needed to compare ATM with static stretching as a

means of preventing hamstring muscle injury or, moregenerally, muscle injury. Second, static stretching tra-ditionally has been included in warm-ups precedingathletic performance, especially where recruitment ofexplosive power is involved. However, there has beenvery little study of the efficacy of this practice. Thefindings of recent studies suggest that running orjumping performance either is not enhanced by32,33 or isnegatively affected by34,35 stretching prior to perfor-mance. Research comparing the results of ATM withstretching prior to running or jumping types of powerperformance would be a useful addition to our knowledge.A third area is adherence to exercise programs amongpeople who have low pain tolerance. In our pilot work andin this study, subjects reported that the ATM process ismore gentle, less of a strain, and generally less painful thanstretching. These reports suggest that there may be betteradherence with the use of ATM in elderly people andpeople who have chronic pain or low pain and stresstolerance. Some support for this idea comes from Phippset al,36 who conducted a retrospective study of a group ofpeople between 20 and 77 years of age with a history oftreatment for chronic pain that included componentsof ATM or yoga. Eighty-five percent of these peoplereported reduction of pain problems, and more than 75%reported continuing to use ATM and yoga techniques ontheir own 2 years after the end of their inpatient programs.More research in this area is suggested.

Finally, the ATM process is different from stretching. Itis important to understand what its mechanism mightbe. Because mechanical explanations seem unlikelyhere, neural mechanisms should be considered. It hasbeen shown that the stretch reflex can be regulated byoperant conditioning,37–39 patterned sensory stimula-tion,40 and skill training.41–44 Further research into thepossible effects of ATM on the stretch reflex or otherneural mechanisms would be enlightening.

ConclusionsWe have shown that hamstring muscles can be length-ened by a method that does not involve stretching.Further research is needed to describe this process, toidentify people who might benefit from it, and tounderstand the mechanisms through which it may work.

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13 McGorry RW, Hsiang SM, Fathallah FA, Clancy EA. Timing ofactivation of the erector spinae and hamstrings during a trunk flexionand extension task. Spine. 2001;26:418–425.

14 Bandy WD, Irion JM. The effect of time on static stretch on theflexibility of the hamstring muscle. Phys Ther. 1994;74:845–850.

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Appendix.Summary of “Awareness Through Movement” Lessons

Introduction• Pay attention to whole-body patterns of movement involving multiple

body segments.• Do movements with the idea of exploring the possibilities about how

they might be done.• Become aware of efforts made in all areas of the body and try to

reduce effort.• Do 5 to 10 repetitions of a movement, then rest.• Movements should be done slowly and easily without pushing or

holding at end-range.• At regular intervals, do a process of scanning by lying in a supine

position and noticing any changes in body-segment relationships,muscle tone, breathing, or ease of small movements.

• Do an equal amount of movement with each leg.• Demonstrate an anterior tilt of the pelvis by placing forearm or towel

roll under the lumbar spine.

Initial Lengthening Concept• Practice pelvic tilting without anything under the back.• Add movements of knee flexion and extension to the pelvic tilting.• Do knee flexion, hip lateral (external) rotation, and posterior pelvic

tilting together and knee extension, hip medial (internal) rotation, andanterior pelvic tilting together.

Side-lying Lesson:• Lie on the left side with the head in the hand or otherwise resting

comfortably.• Abduct the right leg and flex the hip and knee to a 90°/90° position.• Reach the right hand to the right knee.• From this starting position, learn the coordination of combining knee

extension, hip medial rotation, and anterior pelvic tilting and ofcombining knee flexion, hip lateral rotation, and posterior pelvictilting.

• Slide the hand farther down the leg as reaching becomes easier.• Repeat lying on the right side. Rest as needed. Scan at regular

intervals.

Sitting Lesson:• Sit in a long-sitting position with legs a comfortable distance apart and

lean back on hands, if needed.• Place a towel roll under the knees as needed.• From this starting position, learn the coordination of combining knee


• As possible, slide the hands forward down the legs with the kneeextension component of the movement.

• Rest as needed. Scan at regular intervals.

Standing Lesson:• Stand with feet a comfortable distance apart.• Flex the hips and knees and bend forward reaching the hands to touch

somewhere comfortably below the knees.• From this starting position, learn the coordination of combining knee


• As possible, slide the hands farther down the legs with the kneeextension component of the movement.

• Rest as needed. Scan at regular intervals.



doi: 10.2522/ptj.20040208Originally published online January 1, 2006

2006; 86:1641-1650.PHYS THER. Michael Kriz and Nicole SaltzmanJames Stephens, Joshua Davidson, Joseph DeRosa,Stretching Using ''Awareness Through Movement''Lengthening the Hamstring Muscles Without

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